Nicotine replacement therapy for a healthier nation
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7168.1266 (Published 07 November 1998) Cite this as: BMJ 1998;317:1266
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Dear Editor
Although the availability of nicotine replacement therapies on
prescription is to be welcomed, a word of caution must be sounded.
Otherwise the battle against nicotine addiction and its consequences runs
the risk of mirroring the earlier
problems of cervical screening -namely social classes 1-111 will use the
service whilst classes IVand V will not. This is of course inversely
proportional to nedd. Throughout the past two decades social classes I-III
have curtailed their
smoking whilst the others have carried on regardless.
The latter group also includes women and teenage girls of whom
studies have shown are immune to public health education on the topic.
This suggests that these groups are unlikely to come forward for these
replacement therapies - i.e. happy to light -up. Recent editorials have
emphasised the widening gap in state of health between classes and
differential use of health resources. Nicotine patches will not stub out
this chasm.
As with all vices, including alcohol, one of the main limiting
factors is money, or more specifically 'diposable income'.Lower social
classes spend as much as 20% of their disposable income on tobacco as
opposed to less than 1%
higher up the ladder(2). Elasticity of cost in the former was non-
existant, namely increased price resulted in the poor or teenage girls
spending the same amount of money which purchased less cigarrettes or
initially cheaper brands.
This decrease in tobacco consumption was calculated to be a 4.3%
decrease for every 10% increase in price(3). Hughes(4) suggests success
rate for stopping unaided is 3-5% per attempt. If nicotine replacement
therapy doubles quit rate
then the attributable difference would be similar to that achieved by
taxation. Moreover the quitters would be in the target population of
teenage girls and the lower class population. This would result in greater
longer-term outcomes as few take up smoking in adulthood.
Increased taxation reqires not only national government policies -
'rolling tobacco'- was less heavily hit by Kenneth Clarke - but
international co-operation. There ie still wide price disharmony within
the EC not forgetting the
billion pound tobacco-growing subsidy to southern Europe. Also this evil
crop is grown in the USA and owned by a respectable British company in
which many of our PEPs invest. To really change the carnage caused by
tobacco more needs to be done than giving the middle classes patches to
compete for space with their HRT.
Dr At Stmichaels
John williamson
Senior Registrar Psychiatry
St michaels hospital
St michaels road
Warwick
REFERENCES
1) FOWLER G. NICOTINE REPLACEMENT THERAPY FOT A HEALTHIER NATION BMJ
1998 317 1266-1267
2) TOWNSEND J. RODERICK P. COOPER J. CIGARETTE SMOKING BY
SOCIOECONOMIC GROOUP, SEX, AND AGE :EFFECTS OF PRICE , INCOME, AND HEALTH
PUBLICITY BMJ 1994 309 923
3) GODFREY C. MAYNARD A. ECONOMIC ASPECTS OF TOBACCO USE AND TAXATION
POLICY BMJ 1988 297 339-343
4) HUGHES JR THE FUTURE OF SMOKING CESSATION THERAPY IN THE UNITED
STATES ADDICTION 1996 91 (12) 1797-1802
Competing interests: No competing interests
Editor,
Fowler and Smeeth propose making nicotine replacement
therapy available on the NHS believing its high retail price remains
prohibitive to many (1).
A typical 8 week course of 21 mg/24 hour patches bought from a
chemist costs 17 pounds a week but the 20 cigarette a day smoker will save
approximately 20 pounds a week through not smoking whilst using the
patches.
In the Cochrane systematic review of 47 trials including 23,000
patients (2) nicotine replacement therapy doubled smoking cessation rates
at 6-12 months compared to placebo but the authors point out that the
absolute probability of abstinence for an individual remains low and 15
patients would have to use nicotine replacement therapy to
produce one extra abstainer. The authors also note that there seems to be
evidence of publication bias against negative trials and that compliance
with nicotine replacement was lower in smokers treated in primary care.
Before adding yet more pressure to the already strained NHS
perscribing budget and encouraging motivated smokers who currently are
utilising the skills of community pharmacists to instead involve their GP
I am surprised your leading article overlooks the fact that smokers
currently save money even whilst paying for their nicotine replacement
therapy.
I trust this oversight is not related to the manufacturer of one of
the leading brands of nicotine replacement therapy supporting the expert
panel on smoking cessation chaired by
one of the authors.
Yours
Robert Bunney (General Practioner)
Brannam medical centre,
Kiln Lane,
Barnstaple,
N.Devon EX32 8QB
Refs:
1) Smeeth L. Fowler G. Nicotine replacement therapy for a healthier
nation BMJ 1998;7168:1266-7
2)Silagy C, Mant D, Fowler G, Lancaster T. Nicotine replacement
therapy for smoking cessation. In: Cochrane library.Oxford:update
software,1998;issue2.updated quarterly
Competing interests: No competing interests
Dear Editor,
Although increased availability of nicotine replacement therapy is to be
welcomed I fear it would achieve little more than mirror the social class
difference in uptake of cervical smears. Namely the class IV and V target
population would be little affected
Cochrane database suggests with patches a quit success rate that is
near 15%. However Hughes (1) suggests 33% remain abstinent for 2 days
only, and less than 5% succeed per attempt, perhaps a more real life
figure. If patches double this it rises to 10%. Most require in region of
6 attempts, withdrawal symptoms persisting for more than 4 weeks. Should
replacement therapy be prescribed for each attempt? What criteria for
prescribing? Third of adult smokers make a serious quit attempt each year,
all on prescription? 50% of 'want-to-quits' meet DSM IV nicotine
withdrawal criteria.
50% of smokers in their twenties also meet DSM criteria for nicotine
dependence. If this is to change teenagers must be targeted. Each price
increase of 10% results in decreased consumption of 4.2%-5.4%(2), similar
to additional attributed difference of patches. Beneficially, price
preferentially hurts the lower economic classes that are most resistant to
education. However teenage girl smokers whom are the most price sensitive
eclipses this(3).
Very few of us develop social vices after age 25.The regulars in my
methadone clinic want heroin prescribed. Perhaps following their lead,
rather than patches, it should be tobacco on private POM, daily pick-up to
control access to those vulnerable to taking up this horrible addiction.
However this requires a political shift which might disturb the Senator
for Virginia, as poor Thailand found out, or the EC subsidized Greek
tobacco growers. Closer to home, those rich doctors investing in Index
Tracker PEPS may now be proud owners of some weeds in the previously
mentioned Virginia. I suggest that we bat that out of the field.
In reality there will not be a sizeable change until those in power
get out of the pit-lane and take pole-position in fighting this mass-
killer called tobacco. If increasing the availability of nicotine
replacements helps at the individual level then that is to be applauded
but more could be done at national level. Transatlantic tobacco companies
continue to laugh behind their ever-increasing profits. American courts
have tried to force them to increase the price of a packet to, not by,
£1.80.For every ton of tobacco Northern Europe/North America have given up
the third world have started twenty(4). Profits of shame!
References;
1) Fowler G. Nicotine Replacement Therapy for a Healthier Nation BMJ
1998 317 1266-1267
2) Godfrey C. Maynard A. Economic Aspects of Tobacco Use and
Taxation Policy BMJ 1988 297 339-343
3) Townsend J. Roderick P. Cooper J. Cigarette smoking by
socioeconomic group, sex, and age: Effects of price, income, and health
publicity BMJ 1994 309 923
4) PHILLIPS A. DE SAVIGNY D. LAW MM as Canadians butt out, the
developing world light up CMAJ 153(8) 111-4, 1995
HUGHES JR the future of smoking cessation therapy in the United
States Addiction 1996 Dec: 91(12): 1797-802
JOHN WILLIAMSON
SENIOR REGISTRAR PSYCHIATRY
ST MICHAELS HOSPITAL
ST MICHAELS ROAD
WARWICK
HOME 0976621825 HOSP 01926486241 fax 01926 406 702
Competing interests: No competing interests
Re: Nicotine replacement for a healthier nation
Dear Editor: In reading the response made by Dr. Robert Bunney I am
pleased finally to read about the acknowledgement that local community
pharmacists play a role in smoking cessation.
In my community practice, I currently see between 25 to 50 clients
weekly who are attempting to quit smoking. The value of contact with a
pharmacist willing to spend time counselling on appropriate use of
Nicotine Replacement Therapy or other means of cessation, behavioral
modification and timely follow-up is well worth the aforementioned
"prescription charges". In fact, follow-up by pharmacists may be more
cost-effective than the current alternatives. Perhaps governments should
be analyzing the value of paying pharmacists to provide cessation
couselling to the lower socioeconomic groups in terms of "benefits
expressed as cost per life year saved".
Pharmacists are accessible, are well-versed in pharmacological
training, over-the-counter and prescription medications, maintain complete
computerized databases that often allow for flagging for followup, and are
well-connected with appropriate organizations, cessation clinics and
physicians in their communities if referral is necessary.(1) There are
many opportunities for pharmacists to have an large impact when it comes
to intervention strategies for both cessation and prevention of smoking
altogether.(2)
In many areas, pharmacists are specializing in smoking cessation.
For instance, our local health authority is sponsoring workshops for the
health professionals and lifestyle consultants in our area which are being
developed and presented by myself, a local community pharmacist. The
workshop will review current literature and guidelines on cessation
interventions that potentially could impact more smokers than physicians
could see in 6 months.
It is time to acknowledge that smoking cessation is an area that
health professionals must provide seamless care as members of a team. It
is essential to evaluate value of interventions in terms of access to
smokers and education and skill level of the health professional rather
than by professional discipline.(3) The largest impact in terms of
decrease in mortality and morbidity will be realized only when all members
of the health care team work in cooperation.
Yours truly,
Lisa A. DeVos B.Sc. Pharm
Pharmacist Consultant
References:
1. F.S. Layton. Clinical Discussion on Smoking Cessation. Counselling your
patients. Medscape [medscape.com]
2.W.Steven Pray. US Pharmacist 23(7) 1998.
3.Coleman et al. Smoking cessation: evidence based recommendations
for the healthcare system
BMJ 1999;318:182-185 ( 16 January )
Competing interests: No competing interests